INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 1, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Conewago - Pottsville was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven records reviewed.Client #7 was admitted on February 25, 2026, and was discharged on April 27, 2026. Facility staff communicated with the client ' s aftercare provider on May 1, 2026; however, a release of information was not documented in the client record prior to the disclosure.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 7/03/2026, the Clinical Supervisor conducted a comprehensive training on the topic of informed and voluntary consents. Emphasis was placed on ensuring the correct boxes are checked for the disclosure of information contained in the client record that included the purpose of disclosure. On 07/06/2026, the Clinical Supervisor also met with clinical staff individually to provide continued training, answer questions, and get feedback regarding appropriate completion of consents. The Facility Director will monitor the compliance of consent documentation as part of scheduled client chart audits beginning 07/20/2026. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of client records, the project failed to ensure that verbal orders were authenticated in writing by a physician or other medical professional within three business days in four out of seven records reviewed. Client #4 was admitted on October 10, 2025, and was discharged on November 7, 2025. Verbal orders were given on October 22, 2025, that were not authenticated by an authorized provider as of the date of the inspection.Client #5 was admitted on November 20, 2025, and was discharged on December 8, 2025. Verbal orders were given on November 21, 2025, that were not authenticated by an authorized provider as of the date of the inspection.Client #6 was admitted on April 1, 2026, and was discharged on April 28, 2026. Verbal orders were given on April 16, 2026, that were not authenticated by an authorized provider as of the date of the inspection.Client #7 was admitted on February 25, 2026, and was discharged on April 27, 2026. Verbal orders were given on April 16, 2026, that were not authenticated by an authorized provider as of the date of the inspection.The findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 07/14/2026, a Physicians' Meeting was conducted during which the Nursing Supervisor provided re-education to medical staff on the proper completion, population, and electronic signature requirements for documentation within the Enterprise Management System (EM). Training specifically focused on the correct use of the Physician's Orders form, emphasizing that both the attending physician and the nurse must review and sign the form to ensure compliance with documentation standards.
To ensure ongoing compliance, the Facility Director will conduct quarterly random audits of Physician's Orders and related medical documentation within the Enterprise Management System. Audit findings will be reviewed with the Nursing Supervisor, and any identified deficiencies will be addressed promptly through additional education and corrective action as needed. |
709.53(a)(5) LICENSURE Progress Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include group progress notes entered within 72-hours of the date of service, per facility policy, in four out of seven records reviewed.Client #3 was admitted on May 6, 2026, and was a current client at the time of the licensing inspection. The record contained group progress notes for a session occurring on May 11, 2026, that was not documented until May 19, 2026; a session occurring on May 12, 2026, that was not documented until May 19, 2026; and a session occurring on May 18, 2026, that was not documented until May 26, 2026.Client #4 was admitted on October 10, 2025, and was discharged on November 7, 2025. The record contained group progress notes for a session occurring on October 17, 2025 that was not documented until October 24, 2025; a session occurring on October 20, 2025 that was not documented until November 11, 2025; a session occurring on October 27, 2025 that was not documented until November 17, 2025; a session occurring on October 28, 2025 that was not documented until November 17, 2025; and a session occurring on November 3, 2025 that was not documented until November 18, 2025.Client #6 was admitted on April 1, 2026, and was discharged on April 28, 2026. The record contained group progress notes for a session occurring on April 23, 2026, that was not documented until April 30, 2026.Client #7 was admitted on February 25, 2026, and was discharged on April 27, 2026. The record contained group progress notes for a session occurring on March 9, 2026, that was not documented until March 16, 2026; a session occurring on April 23, 2026, that was not documented until April 30, 2026; and a session occurring on April 22, 2026, that was not documented until May 2, 2026.This is a repeat citation from the July 18, 2025, annual licensing renewal inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 7/03/2026 Clinical staff were retrained on Firetree's policy that group progress notes must be entered within 72 hours of the date of service. In regards to the content covered for the due dates for group progress notes staff were trained that group progress notes are due no later than 72 hours after the group session is concluded. To ensure future compliance the Clinical Supervisor and Facility Director will audit charts on a weekly basis to ensure they are completed in the proper timeframe. |